Basic Information
| Provider Information | |||||||||
| NPI: | 1306904222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | K'IMAW MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOOPA HEALTH ASSOCIATION | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 AIRPORT ROAD | ||||||||
| Address2: | PO BOX 1288 | ||||||||
| City: | HOOPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955461288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306254261 | ||||||||
| FaxNumber: | 5306259308 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | HOOPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955469615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306254261 | ||||||||
| FaxNumber: | 5306259308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHASE | ||||||||
| AuthorizedOfficialFirstName: | EMMETT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5306254261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | EXEMPT INDIAN TRIBE | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | EAP11573F | 01 | CA | EAPC | OTHER | PHE43666 | 01 | CA | PHARMACY | OTHER | THP11573F | 05 | CA | MEDICAID | 05D0699458 | 01 | CA | CLIA | OTHER | BK6251502 | 01 | CA | PHARMACY DEA | OTHER | PHE436660 | 01 | CA | PHARMACY MEDICAID NUMBER | OTHER | 005540 | 01 | CA | BC COUNTY MEDICAID | OTHER | 0533922 | 01 | CA | PHARMACY NABP | OTHER |